Clinical Practice Points

The U.S. Preventive Services Task Force recommends aspirin for primary prevention of cardiovascular disease (CVD) and cancer among adults aged 50 to 59 years with a 10-year CVD risk of 10% or higher. Several prognostic models estimate the potential cardiovascular benefits of using aspirin for primary prevention, but despite a comprehensive literature review, the Task Force could not identify a suitable model to predict bleeding risk with aspirin use. This study describes a prognostic model to estimate bleeding risk among persons in whom aspirin may be considered for primary prevention.

Use this study to:

Start a teaching session with a multiple-choice question. We've provided one below!

Ask your learners whether they discuss primary prevention of CVD with their patients. What do they talk about? Do they use a tool to assess cardiovascular risk?

Do your learners recommend aspirin for primary prevention? If so, how do they weigh the risks versus the benefits? Will the results of this study help them?

What are the barriers to use of the PREDICT model reported in this study? Why is external validation of a prediction model necessary? Use the accompanying editorial to help frame your discussion.

How is the performance of a predictive model assessed? What are discrimination and calibration? How are receiver-operating characteristic curves and reclassification indices useful? Invite an expert in epidemiology or biostatistics to help discuss these important topics with your learners.

Nearly 30% of patients receiving maintenance hemodialysis have symptoms of depression, but most are not treated for it. This multicenter, randomized controlled trial examined whether an engagement interview increased hemodialysis patients' willingness to be treated for depression and then compared the efficacy and safety of cognitive behavioral therapy versus sertraline treatment.

Why do your learners think that despite being so common among patients requiring maintenance hemodialysis, depression is usually not treated? Do we fail to recognize the problem? Are patients reluctant to accept the diagnosis?

How would your learners assess a patient for possible depression? What questions would they ask? Are there screening tools they would use?

How would your learners counsel a patient who they thought was depressed but reluctant to accept treatment? What treatments would they discuss? Use the accompanying editorial to help frame your discussion. How do you arrange for cognitive behavioral therapy? Are commonly used drugs for depression safe among dialysis patients?

This Annals for Hospitalists paper discusses important considerations when choosing the method of venous access for a 60-year-old man with sepsis.

Use this paper to:

Ask your learners what the indications for central venous access are.

Read the presentation of the patient to your learners and ask whether they believe central venous access is required. If so, what kind of line?

What are the relative benefits and risks of traditional central venous catheters (CVCs) and peripherally inserted central venous catheters (PICCs)?

What are the options for central venous access at your institution? Who places each type, and how is placement arranged? Does the availability or ease of arranging for one type of line versus another (e.g., a CVC vs. a PICC) sway the decision at your institution? Should it?

Are central lines ever placed for inappropriate reasons or left in longer than they should be? Is patient or provider convenience an appropriate reason for central access?

Ask your learners whether they have heard more senior physicians telling stories of “the old days.” Have the old days ever been referred to as “the days of the giants”? Were they?

What was better in “the old days,” and what has improved? Invite physicians who have practiced medicine for decades to join your discussion.

Do your learners seek out the wisdom of the most senior members of your staff? What might they offer that others cannot? What can your learners offer them?

MKSAP 18 Question

A 51-year-old woman is evaluated during a routine follow-up visit for diabetes mellitus. She also has hypertension and hyperlipidemia. Medications are metformin, enalapril, chlorthalidone, and high-intensity rosuvastatin. She has no drug allergies.

On physical examination, blood pressure is 126/74 mm Hg. The remainder of the examination is unremarkable.

Her 10-year risk for atherosclerotic cardiovascular disease is 11% according to the Pooled Cohort Equations. She has been instructed in intensive lifestyle modifications.

Which of the following is the most appropriate preventive measure to reduce this patient's cardiovascular risk?

The most appropriate measure to reduce this patient's atherosclerotic cardiovascular disease (ASCVD) risk is low-dose aspirin. The U.S. Preventive Services Task Force (USPSTF) recommends low-dose aspirin for the primary prevention of ASCVD and colorectal cancer in adults aged 50 to 59 years with a 10-year ASCVD risk of 10% or higher who do not have an increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. In those aged 60 to 69 years with a 10-year ASCVD risk of 10% or higher, the benefits of aspirin use for primary prevention are smaller but still outweigh the risk for bleeding, and the decision to initiate low-dose aspirin in this population should be individualized. In contrast to the USPSTF recommendations, the American Diabetes Association recommends consideration of low-dose aspirin therapy as a primary prevention strategy in patients with type 1 or type 2 diabetes mellitus who are at increased cardiovascular risk. This group of patients includes most men and women with diabetes aged 50 years or older who have at least one additional major risk factor (family history of premature ASCVD, hypertension, dyslipidemia, smoking, or albuminuria) and are not at increased risk for bleeding. Aspirin therapy for the primary prevention of ASCVD is likely underused (approximately 40% of eligible candidates). Among patients told by a physician to take aspirin, 80% adhere to the recommendation.

For patients with ASCVD and documented aspirin allergy, the ADA recommends clopidogrel as an alternative preventive measure. This patient does not have a documented aspirin allergy, and therapy in this patient will be initiated for primary, not secondary, prevention; therefore, clopidogrel is not recommended for this patient.

The most commonly recommended dose of aspirin for primary prevention of cardiovascular events is 75 mg to 100 mg. Primary prevention trials have shown that lower doses are likely as effective as higher doses; however, observational trials and a meta-analysis have demonstrated an increased risk for bleeding with regular-dose aspirin compared with low-dose aspirin.

This content was last updated in January 2018.

Key Point

Low-dose aspirin for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and colorectal cancer is recommended for adults aged 50 to 59 years with a 10-year ASCVD risk of 10% or higher who do not have an increased risk for bleeding.

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